It’s the platform, stupid

I read with interest a recent article by my favorite health care reporter, Joe Conn, who has long time interest in the commercial success of the VistA Electronic Health Record system developed by the VA.

VistA has an incredible, well described impact on the clinical and
system peformance of the VA. Given its availability through the Freedom
of Information Act, it can and should seriously be considered as a
potential solution for government-based health care information
technology. I mean, why not? The several billion dollars already
invested, and the several billion dollars already wasted on
alternatives, would hopefully help the new administration come to their
senses to realize the development of a common platform for all
government related health IT would make good business sense.

In the past, this notion has been fought by the other departments
who have “special” needs (NASA needs their own system, Indian Health
Services has a different focus, DoD needs increased mobility, etc).
Whatever the “smoke screen” reason is, the fact of the matter is that
these departments are protecting their turf and their budget. However,
all of these entities have some basic functionality that is required of
any basic system (Patient Information Management, Laboratory, Pharmacy,
Radiology, Notes, etc) that are shared across the departments. This
“basic system” should be conceived of as the core platform from which
the modular functionality can be built. Everyone develops to the common
core and creates “apps” (modules) that tie into the generic platform
but serve specialized needs.

I don’t think anyone would argue with the success of the Facebook platform, nor the various app extensions that have been automonomously developed by its users? Would anyone argue against the Apples iPhone platform and App
store framework? Well, it seems that VistA has the potential, certainly
within the Federal Health care space*, to become the defacto platform
from which to build.

But what about the private sector? Does VistA have a similar
opportunity.  Among many issues that prevent the widespread adoption of
VistA in the commercial sector, one unfortunately persistent problem is
what “version” of the platform should we use (WorldVistA, OpenVista, vxVistA, or flavorofthemonthVistA). While this is irritating and groups like World VistA and the VistA Software Alliance
have been wrangling with this issue since 2002, it belies a more
fundamental problem with the widespread adopting VistA  – it actually
isn’t (or as currently constructed) a viable platform.

What? Heresy? What say you?

The inestimable foundational system from which VistA is based is MUMPS. MUMPS is both a programming language and a database all conjoined into one ugly mess that only a mother could love.
The story of MUMPS, and its use within the VA is quite fascinating, and
the religious fervor of its faithful and its detractors is epic.
However, then nature of MUMPS makes it actually quite hard to
“modularize” VistA. You can’t really cleanly delineate between parts
and subparts, from routines and runtimes, and most importantly
demarcate between the notion of a “platform” and the specialized apps.

This has led to commercial challenges in extending the system,
having to swallow the software “whole” without the inability to easily
integrate other IT investments, or the limited ability of third party
development shops to rally around the platform by creating supporting
apps that meet critical market feature/functionality needs. Until this
problem is solved – until we get to some layers of abstraction within
the technology stack – VistA will continue to bump along in its
adoption, we will continue to be mired in forking conversations, and
bogged in difficult licensing issues to work out that prevent true

I am hoping someone, anyone, who is interested in VistA’s commercial
success will be able to create the platform/app separation that I would
argue is required for VistA’s long term commercial success.

* There are specific reasons why VistA can and should become the de facto standard within the Federal Health System:

  1. The VA is the largest health care system in our country with
    over 160 medical centers and 1,300 clinics all utilizing essentially
    the same software.
  2. All the current information technology systems are derived from
    it (Both the DoD and IHS use a variation of VistA) and therefore share
    significant architectural similiarities.
  3. VA has been by far the most successful historical in achieving
    clinical transformation through the use of information technology;
    although IHS is by far the most innovative now health care IT branch of the Federal Health System thanks to the vision of CIO Terry Cullen, MD.

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Scott Shreeve, MDBilly JacksonJohn M. Grohol, PsyDDr. Rick LippinRuss Bourke Recent comment authors
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Scott Shreeve, MD

To Billy Jackson, Thanks for your note . . . please see my followup post: http://blog.crossoverhealth.com/2009/01/12/sales-objection-2-mumps-is-dead-no-its-actually-epic/ I am actually a huge fan of MUMPS, given its commercial success and real time performance in the largest implementations in health care IT. However, to become even more pervasive I want to see MUMPS based systems adopt some of the lighter weight, agile, flexible new tools to continue to give vitality to this proven technology. To JFS, Love the quote, “Its a dog and an old one at that”. It belies a very important point. VistA in and of itself does not measure… Read more »

Billy Jackson

Hi Scott, I love the points you make in regards to architecture being the foundation for agility! Your point about mumps though leaves a pretty big opening for folks who would argue that it’s not the weak platform that you profess. Specifically that there are still multiple commercial healthcare apps, and some big ones too, that still run on mumps. I can think of McKesson (STAR ADT/Billing/Radiology) and Antrim (now Cerner) lab. Last but not least Cache, the newest incarnation of mumps is the engine for GE Centricity Business that’s still implemented as a bunch of globals and one letter… Read more »

John M. Grohol, PsyD

Russ’s comments about VistA and HIMSS are right on. We need to start demanding that government agencies and other organizations stop the turf-protecting, which is only costing the industry millions of dollars and incompatible EHR implementations. VistA has a lot to offer the industry and a lot of potential. Perfect? Far from it, but others could learn a lot from its implementation within the VA system.

Dr. Rick Lippin

Conversely if you want to study a huge Government HIT system to learn what NOT to do with HIT, study the DoD’s AHLTA. It is an abyssmal disaster.Niko Karvounis from HealthBeat Blog and in an article he did for Mother Jones tells the sad tale of this monumental failure.Even the DoD itself is becoming more transparent about AHLTA’s failures.What a mess.
Dr. Rick Lippin

Russ Bourke
Russ Bourke

Scott, Thank you for an excellent post elevating a discussion of VISTA! Your article clearly articulates the advantages to the VISTA platform: 1. A well developed core system -Patient Information Management, Laboratory, Pharmacy, Radiology, Notes, 2. Safety and Quality features are bundled including machine readable technologies (Bar code & RFID) 3. VISTA system is in place at the national level spanning the United States, operational and fairly efficient managing upwards of 25 million veterans with scalability to handlemuch more. There is no commercial equivalent to this. 4. US Taxpayers need to realize the value of their investments and leverage that… Read more »


VistA in and of itself is not a success. Overall it is a dog, and an old one at that. The success is the VA system and VistA implementation within its unique environment.
One man’s opinion.